Application Form & Full Disclosure Of Ownership Statement For An Amended License By An Individual, Partnership, Limited Liability Company Or Corporation Page 3

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Division of Public Health –Licensure Unit–Children's Services Licensing
Application & Full Disclosure of Ownership Statement for an Amended License
by an Individual, Partnership, Limited Liability Company or Corporation
READ CAREFULLY, USE BLACK INK, PRINT LEGIBLY AND FOLLOW ENCLOSED INSTRUCTIONS
SECTION C - FACILITY INFORMATION:
FOR FAMILY CHILD CARE HOME I ONLY: This program must be in the applicant’s residence.
Do you own the home where the program is located?
Yes
No
If you rent or lease the property, give the name, address and phone number of the owner/landlord (landlord information
may be verified):
___________________________________________________________________________________________________________________________
FOR FAMILY CHILD CARE HOME II, CHILD CARE CENTER, SCHOOL-AGE-ONLY CENTER OR PRESCHOOL:
Do you live on the premises?
Yes
No
Where is the program located?
House
School
Church
Free Standing
Strip Mall
Store Front
Other (Describe): _________________________________________________________________________________________
Do you own the property where the program is located?
Yes
No
If you rent or lease the property, give the name, address and phone number of the owner/landlord (landlord information
may be verified):
___________________________________________________________________________________________________________________________
SECTION D - HOUSEHOLD INFORMATION:
This section must be completed for ALL programs when
the child care/preschool is located in a residence. This page may be copied as needed.
List below ALL persons residing at the child care/preschool program address INCLUDING yourself, spouse, significant other,
children, grandchildren, foster children, relatives, roommates and any individual regularly present.
BIRTH
RELATIONSHIP TO
OTHER NAME/S USED
SOCIAL SECURITY
LEGAL NAME
DATE
APPLICANT
(maiden, alias,
NUMBER
(last, first, middle Initial)
previously married, nickname)
MM/DD/YY
(i.e., son, daughter )
SECTION E - STAFF INFORMATION FOR FAMILY HOMES I AND II ONLY:
List below ALL persons who are designated as: primary provider, staff, substitutes, or volunteers.
This page may be copied as needed.
BIRTH
WORK
OTHER NAME/S USED
SOCIAL SECURITY
FTE
LEGAL NAME
POSITION
DATE
SCHEDULE
(maiden, alias, previously
(last, first, middle Initial)
NUMBER
(i.e., Staff)
PTE
married, nickname)
MM/DD/YY
(i.e., Hours Days)
3
CRED-0949 (25023) 5/14

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